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Ur:IFIED PROGRAM CONSOLIDATED FCR,n <br /> TA;JKS <br /> UNDERGROUND STORAGE 1 ANKS -TANK PAGE 1 �I <br /> (two pages per tank) !� <br /> Page _ of <br /> •�TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT W, CHANGE OF INFORMATION) K ❑ 8. TEMPORARY SITE CLOSURE <br /> (Check one dem only) /e-w t ��J f�`� <br /> /V G� 7. PERMANENTLY CLOSED ON SITE <br /> ❑3.RENEWAL PERMIT (Specify mason-for local use-nly) (Specify change-for.ocal use on(y) S. TANK REMOVED 430 +`O <br /> 1 <br /> BUSINESS NAME;Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID# 1 <br /> kI; boot ► y <br /> LO ATI WiTr1.N SITE(Optional 431 <br /> I.T'�`JK DESCRIPTION <br /> TANK 10# TANK MANUFACTURER COMPARTMENTALIZED TANK ❑ Yes Fpe. <br /> / YO o ,o /•n,/ If'Yes',complete one page for each compartment. <br /> DATE INSTALLED(YEAR/MO) TANK CAPACITY IN GALLONS col' NUMBER OF COMPARTMENTS <br /> ADDITIONAL DESCRIPTION(For local use only) <br /> II.T414116CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> 1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED El 2. LEADED � ❑ 5. JET FUEL <br /> (Il marked.complete Petroleum Type) ❑tb. PREMIUM UNLEADED lld 3. DIESEL ❑ 6. AVIATION FUEL <br /> ❑ 2. NON-FUEL PETROLEUM ❑tc MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> COMMON NAME(hom Hazardous Matenal Inventory page) CAS#(from Hazardous Matehals Inventory page) <br /> ❑ 4. HAZARDOUS WASTE(Includes <br /> Used Oil) <br /> cc UNKNOWN <br /> CONSTRUCTION <br /> TYPE OF TANK 1 IN LIE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Crack one item only) 2. DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL-primary lank ❑ 1 BARE STEEL 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑99. OTHER <br /> _BEINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ❑ 1 BARE STEEL 3. FIBERGLASS I PLASTIC ❑ 8. FRP COMPATIBLE vVI100%METHANOL ❑95. UNKNOWN <br /> (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4 STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) ❑10. COATED STEEL <br /> ❑ <br /> S. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ 5. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> 112. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑99. OTHER <br /> (Check one item only) (Forlocal use only) <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC ❑ 3. FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE <br /> PROTECTION ❑ 4. IMPRESSED CURRENT ❑99. OTHER <br /> (Check one item only) ❑ 2. SACRIFICIAL ANODE (For local use only) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all that apply) 1. SPILL CONTAINMENT1. LARM 3. -'LL TUBE SHUT OFF VALVE <br /> 2'2. DROP TUBE ALL FLOAT D `%r-AEMPT <br /> STRIKER PLATE <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one aem only): <br /> ❑ 1. VISUAL.EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE 11'2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUS ATG ❑ 7. GROUNDWATER ❑ 3. MANUAL MONITORING <br /> ❑ 4. STAT.3'ICAL INVENTORY RECONCILIATION(SIR)r ❑ S. TANK TESTING <br /> BIEN:,AL TANKTESTING ❑99 OTHER <br /> V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE <br /> �3 .YATEC- "c LAST USED(YRIMCiDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> gallons ❑Yes ❑No <br /> ICU <br /> 6131) <br /> CUPAFORM(4 9') Formerly SWRCB Form B <br />